OK, here's a callout of mine from the other night. It has been embellished slightly for the purposes of making it a little more challenging.

You're in the process of securing a drug house after serving a search warrant. 3 subjects are in custody, and are being searched. Your intel reports that there should have been 4 subjects in the residence. The residence has been searched extensively, and only the 3 subjects are present. At that time, you hear over the radio "vehicle moving, alley, side 3." Followed by "oh my god he hit him!" You begin making your way to the rear of the structure when you hear your teammates yelling "Police! Police! Drop the gun!" This is followed by a single pistol shot, then 2 bursts from what you recognize as an MP5-SD. This is then followed by, "Medic up! Medic up!"

You make your way into the alley and discover 2 patients.

Patient 1 is a 4 y/o male who is lying prone under the front bumper of a midsize sedan with a significant amount of blood about his head. He is not moving and not making any noise.

Patient 2 is a 25-30 y/o male who is lying supine in the alley and appears to have several pistol-caliber gunshot wounds high in his chest. He is pulseless and apneic. He is identified as subject #4 from the house. He was the driver of the vehicle that struck the child during his attempt to escape. He engaged one of the perimeter officers after exiting the vehicle with a single pistol shot, and was neutralized by the perimeter officer.

You are the only medic on the team. Take it from there...

Andy

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Air goes in and out, blood goes round and round...any deviations from this are a bad thing.

I'm no cop - hell, I've never even played one on TV OR the Internet. Still, I would be awful tempted to spend A LOT of time making sure the 4 year old was OK - and if unresponsive, would spend more time than possibly normal trying to revive him.

"Oh, the other guy? I guess in all the stress of the situation I overlooked him."

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During the rectification of the Vuldronaii the Traveler came as a large, moving Torb. Then, during the third reconciliation of the last of the McKetrick supplicants they chose a new form for him—that of a giant Sloar. Many Shubs and Zuuls knew what it was to be roasted in the depths of the Sloar that day, I can tell you.

I have officers around, meaning I have first responders to assist.
Grab 2 of them and get one on each casualty.

Get another guy to move the car out of the way so I don't have to move the kid.

Suspected injuries is a frontal impact to the 4 y/o's torso region, then hitting the ground.

What do I have for visible life threats?

What does the first responder tell me about chumpman with the burst to the chest? vitals?

My primary concern is the kid, because he's got a chance at surviving and growing up good. Plus, a oxygen thief with 2 bursts of 9mm from a mp5 to the chest, in that area stated, with no RBA..... my money is on expectant if not already dead. Main focus of checking him out is to ensure he IS for legal reasons. Did what I could, yadda yadda.

If kid has a pulse, I work him-because the bad guy doesn't have one at this point...

If I am the only medic on the ground, I will focus my efforts on the patient that has a statistically better chance of surviving...would attempt to talk one of the other officers through the patching of the the bad guy as RIT Medic suggests, however the kid goes in my first transporting unit to arrive...because at this point I have labeled the bad guy as expectant...

In the current system I work in you could work this under two ways like mad medic said triage who has the best chance, our protocols say if penertrating trauma arrest is greater than 10 minutes out- they are black tagged. I can't imagine any cop offering to do CPR on the bad guy but hey
I would still ask for two units, more man power plus someone might have to cut paperwork on the pulseless/nonbreathing guy.
kary

Originally posted by themadmedic If kid has a pulse, I work him-because the bad guy doesn't have one at this point...

If I am the only medic on the ground, I will focus my efforts on the patient that has a statistically better chance of surviving...would attempt to talk one of the other officers through the patching of the the bad guy as RIT Medic suggests, however the kid goes in my first transporting unit to arrive...because at this point I have labeled the bad guy as expectant...

i think the given scenerio is an easy call.... the gsw victime is in arrest so you can justify putting all your efforts on the child as the one with the more survivable injury... especially if the gsw's weren't isolated to the chest.

what if the scenerio was reversed.... the child is in full arrest after being shot and the suspect was the one hit by car and found down but not in arrest?

I have to assume that someone (team guys you trained??) did Primary surveys on both as we were given the mentioned facts. And that since that was done that the suspect has been searched/cuffed.
If this is not the case, then devote no more time to him; have team pull security on him (hopefully this is your SOP)until you can finish the eval/resus on the civilian/child.
To continue, I fully agree with DocT;triage protocols all say that traumatic codes are down the list. The child may have a simple concussion/closed head injury all the way up to intracranial bleeding/swelling along with ortho injuries, abd/chest injuries. Rapid assessment and transport is the key. There is nothing anyone in the field can do for this kid. He needs a doc and probably an OR.
So ABCs,full c-spine precautions, airway, IV's if possible, oxygen therapy and quickly transport.
Again I assume your team has transport options already squared away per SOP since you are doing a full tactical operation/warrant service.
From my perspective this is as much tactical as medical: SECURITY always comes first! My SWAT SOP for multiple casualties was to simply secure the suspect and treat others. It takes alot of time to properly SEARCH not pat down etc suspects, then secure them. Time that can be spent evaluating and treating non hostiles. This follows with scene safety etc.
It is really easy to just say Fu.. em as far as the suspect is concerned- till you have to testify in a wrongful death action. Then ya gotta have ur ducks in a row....The above course of action has been upheld multiple times including LAPDs North Hollywood dust-up.

The child is unconscious, breathing agonally, has a left temporal open skull FX with active arterial bleeding, and has a bounding carotid pulse of 68. There appears to be some bruising over the anterior chest as well.

The BG is cuffed, has had a cursory search performed, and is still pulseless and apneic...

SOP is for 1 ALS transport ambulance (1 medic, 1 EMT) to stage a block away for warrant services. An additional ambulance is 10-12 minutes out. Helo has a standard ETA of 15 mins if called.

All operators are trained in CPR/First aid, and have basic knowledge of other medical skills (how to squeeze a BVM, setup an IV, etc).

Perimeter is secured.

Keep it going...

Andy

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Air goes in and out, blood goes round and round...any deviations from this are a bad thing.

Adv the Team Leader the support ambulance is needed to transport the child, and second in ambulance is needed for the suspect, who is expectant Not sure of your transport time vis a vis the helo. When the T/L has a warm n fuzzy about security, he can call them (ambulance) forward. At the same time the team can begin BLS on the suspect.

All of my attention is given to the pediatric patient until care can be transferred to the transport crew. Treatment same as above with open Fx being bandaged/dressed. High flow O2 and high flow ambulance. First out.

After suspect has been secured BLS procedures begun on him and then ALS after I am freed up. He is expectant, but having seen him go down there might be some scrutiny if a wrongful death suit is filed by the family for "just letting him die."

James D.

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Acronyms; those clever abbreviations created so Medics are not embarrased by their inability to spell words they can barely pronounce.--ME

Doc T's question makes things a bit more interesting...
Again, this type of situation is not solved at the time it happens. If ur team doesnt have the answer figured out in training, on the day it is too late!

The suspect is secured by the operators. They should be pulling security, not treating. HE IS STILL DANGEROUS!!

And whether you are a cop-medic or civiliian medic (fire etc) you should be focused now on strictly medicine, not worrying about security. Since you cant treat the suspect yet (not secure) you treat the kid. In fact you may decide to move him away from suspect if in close proximity, secure him from harm with a shield etc. Then work him up like any other penetrating trauma. Airway/OPA/ETT, Breathing/occlusive dressings/chest decompression, Bleeding/control (not necessarily stop...) hemmorhage, spinal precautions, IV's and quickly transport. Again he needs the services of Doc T and her Trauma Team NOW. Although traumatic codes have a very low survival rate, this kid deserves our best efforts....
For the record, so does the suspect; when he is secure and when we can move our attention from the kid (who we started with since he is "secure") and in all liklihood when the standby ALS rig gets there cause it will take that long to work the kid.

Triage protocols are not violated. Every class I have ever taken or taught at all levels start with "Scene Safety"

Something that was going through my mind regarding treating the GSW victim, is that I am at his side less than a minute after he was shot, and he is already in full arrest. I'm 20-plus minutes from the Trauma Center. What are is chances? Probably slim enough for me to black tag him and move on. But that's just me.

Andy

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Air goes in and out, blood goes round and round...any deviations from this are a bad thing.

Originally posted by TacMedic105 Something that was going through my mind regarding treating the GSW victim, is that I am at his side less than a minute after he was shot, and he is already in full arrest. I'm 20-plus minutes from the Trauma Center. What are is chances? Probably slim enough for me to black tag him and move on. But that's just me.

Andy

greater than 20 minutes down typically means no signs of life by the time you would arrive to an ER... meaning, no rhythm, no pupillary action, etc... therefore, most algorithms for cardiac arrest from penetrating trauma put the cut off to ER thoracotomy at 20 minutes from time of arrest.

In a child most people would still tend to do the thoracotomy since children are just a different entity from adults and can often survive (with function) when adults cannot.

I'm not certain what your team's/medical director's SOP for this is but...

For an injury such as this, pulseless/apneic/with penetrating trauma to the head or central chest wound, our guidelines don't require any resucitative effort to be initiated unless the patient is found to be in VF/VT. So, if the suspect in question had been mine, we would have BLS'd him until we could confirm the rhythm as asystole or PEA (with doppler confirmation) and then terminate effort.

Would be interested in knowing what your meddir's policy is for this type of patient.

I'm not certain what your team's/medical director's SOP for this is but...

For an injury such as this, pulseless/apneic/with penetrating trauma to the head or central chest wound, our guidelines don't require any resucitative effort to be initiated unless the patient is found to be in VF/VT. So, if the suspect in question had been mine, we would have BLS'd him until we could confirm the rhythm as asystole or PEA (with doppler confirmation) and then terminate effort.

Would be interested in knowing what your meddir's policy is for this type of patient.

Yes. Actually, the protocol allows you to use clinical judgement as to whether or not to initiate resucitative effort on the patient if they are found to be in VF/VT. The protocol does not require a patient to be placed on the EKG if they are found to be the victim of a penetrating injury to the head, neck, or chest and are pulseless, apneic with pupils fixed and dilated. Our medical director has issued the caveat of the VF/VT to allow us some latitude in treatment.

Yes. Actually, the protocol allows you to use clinical judgement as to whether or not to initiate resucitative effort on the patient if they are found to be in VF/VT. The protocol does not require a patient to be placed on the EKG if they are found to be the victim of a penetrating injury to the head, neck, or chest and are pulseless, apneic with pupils fixed and dilated. Our medical director has issued the caveat of the VF/VT to allow us some latitude in treatment.

Thoughts?

if they are fixed and dilated and have not recieved atropine I quit... if atropine is on board then i am not always certain what to do and err on the side of trying. I have had one survivor from a stab wound who arrived in PEA... neurologically intact... that is why I questioned it... think stabs are a bit different than GSWs even though both are classified as penetrating...

just my 2 cents... have opened a bunch of chests with very few survivors but knew many of the thoracotomies were for teaching benefit more than any real chance of survival...

A follow-up thought. We don't initiate ALS effort for traumatic PEA in some specific cases, we don't terminate ALS effort for PEA once initiated. I'm referring only to trauma and not medical with regard to all the rule-out criteria causes of the rhythm.

A follow-up thought. We don't initiate ALS effort for traumatic PEA in some specific cases, we don't terminate ALS effort for PEA once initiated. I'm referring only to trauma and not medical with regard to all the rule-out criteria causes of the rhythm.